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Thousands of claims through five chained decisions

Each claim passes through five separate decision tables (67 rules in all). What one decides becomes the next one's input: severity drives the fraud screen, both drive the route, the route decides how the customer hears back. Change the week and watch the flows shift.

Scenario
Claims
  1. 1 Triage 22 rules · –
  2. 2 Fraud screen 14 rules · –
  3. 3 Coverage 11 rules · –
  4. 4 Settlement route 11 rules · –
  5. 5 Customer update 9 rules · –
Trace one claim

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    Claims
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    Decisions
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    Chain time
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    Paid at once
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    How it works

    1. Five separate tables

      Triage, fraud screen, coverage, settlement route and customer update are separate decisions. Each one can be owned and edited by a different team.

    2. Outputs become inputs

      Severity from triage feeds the fraud screen and coverage; all three feed the route; the route and plan decide how the customer hears back.

    3. A batch per step

      Each step resolves the whole batch of claims in one request, then hands its outputs to the next. The flow chart shows where every claim ended up.

    4. Trace any claim

      Click a node to filter, or trace a single claim to see the rule that decided it at every step.

    1 · Triage 22 rules · first match wins

    Policy, as writtenGrade each claim's severity. Windscreen claims are minor up to €1,500, otherwise moderate. Collisions: minor up to €1,500, moderate up to €8,000, major up to €30,000, catastrophic above. Theft is moderate up to €15,000, major above. Water damage: minor up to €2,000, moderate up to €12,000, major above. Storm: minor up to €3,000, moderate up to €20,000, major up to €80,000, catastrophic above. Fire: moderate up to €5,000, major up to €60,000, catastrophic above. A collision, water or storm claim over €500 with no photos is at least moderate.

    # Claim typeAmount (€)Photos supplied Severity Hits
    1 Collision500–1500no Moderate
    2 Water damage500–2000no Moderate
    3 Storm500–3000no Moderate
    4 Windscreen≤ 1500· Minor
    5 Windscreen·· Moderate
    6 Collision≤ 1500· Minor
    7 Collision≤ 8000· Moderate
    8 Collision≤ 30000· Major
    9 Collision·· Catastrophic
    10 Theft≤ 15000· Moderate
    11 Theft·· Major
    12 Water damage≤ 2000· Minor
    13 Water damage≤ 12000· Moderate
    14 Water damage·· Major
    15 Storm≤ 3000· Minor
    16 Storm≤ 20000· Moderate
    17 Storm≤ 80000· Major
    18 Storm·· Catastrophic
    19 Fire≤ 5000· Moderate
    20 Fire≤ 60000· Major
    21 Fire·· Catastrophic
    22 ··· Moderate
    2 · Fraud screen 14 rules · first match wins

    Policy, as writtenScore fraud risk. High: theft without a police report, a major or catastrophic claim on a policy under 2 months old, 4+ prior claims, or a non-minor claim reported more than 60 days late. Storm claims that are catastrophic are a known peril: low. Medium: 2+ prior claims on a policy under a year old, reports more than 30 days late, moderate claims on policies under 6 months, major or catastrophic fires, and major or catastrophic collisions without a police report. Otherwise low.

    # Severity (step 1)Claim typePolicy age (months)Prior claimsDays to reportPolice report Fraud riskSignal Hits
    1 ·Theft···no High Theft without police report
    2 Major·< 2··· High Large claim on a new policy
    3 Catastrophic·< 2··· High Large claim on a new policy
    4 ···≥ 4·· High Frequent claimant
    5 ≠ Minor···> 60· High Reported very late
    6 CatastrophicStorm···· Low Known storm event
    7 ··< 12≥ 2·· Medium Repeat claims, young policy
    8 ····> 30· Medium Reported late
    9 Moderate·< 6··· Medium New policy
    10 MajorFire···· Medium Large fire
    11 MajorCollision···no Medium Large collision, no police report
    12 CatastrophicFire···· Medium Large fire
    13 CatastrophicCollision···no Medium Large collision, no police report
    14 ······ Low No signals
    3 · Coverage 11 rules · first match wins

    Policy, as writtenWork out coverage. Basic plans exclude theft, water damage and windscreens; cover fire in full with a €500 excess; cover collisions partly with €750 excess and storms partly with €1,000 excess. Comprehensive plans cover everything in full with a €250 excess, except catastrophic storms (partial, €2,500) and major water damage (partial, €1,000). Premium plans cover everything in full with no excess.

    # PlanClaim typeSeverity (step 1) CoveredExcess Hits
    1 BasicTheft· Excluded None
    2 BasicWater damage· Excluded None
    3 BasicWindscreen· Excluded None
    4 BasicFire· Full €500
    5 BasicCollision· Partial €750
    6 BasicStorm· Partial €1,000
    7 ComprehensiveStormCatastrophic Partial €2,500
    8 ComprehensiveWater damageMajor Partial €1,000
    9 Comprehensive·· Full €250
    10 Premium·· Full €0
    11 ··· Partial €500
    4 · Settlement route 11 rules · first match wins

    Policy, as writtenRoute each claim. Not covered: decline. High fraud risk, or medium risk on a major or catastrophic claim: special investigation. Pay instantly when it's minor, low risk and up to €2,500, or moderate, low risk, fully covered and up to €5,000. Medium risk goes to desk review. Major and catastrophic claims get a field adjuster. Partly covered claims go to desk review. Everything else: desk review.

    # Severity (step 1)Fraud risk (step 2)Covered (step 3)Amount (€) Route Hits
    1 ··Excluded· Decline
    2 ·High·· Investigation
    3 MajorMedium·· Investigation
    4 CatastrophicMedium·· Investigation
    5 MinorLow·≤ 2500 Instant payout
    6 ModerateLowFull≤ 5000 Instant payout
    7 ·Medium·· Desk review
    8 Major··· Field adjuster
    9 Catastrophic··· Field adjuster
    10 ··Partial· Desk review
    11 ···· Desk review
    5 · Customer update 9 rules · first match wins

    Policy, as writtenTell the customer. Instant payouts: app notification, paid today. Declines: Premium customers get a phone call within 24 hours, others an email within 48 hours. Investigations: email within 5 days. Field adjuster: phone within 2 hours for catastrophic claims, within 4 hours for Premium, otherwise within 24 hours. Desk review: phone within 24 hours for Premium, otherwise email within 3 days.

    # Route (step 4)PlanSeverity (step 1) ChannelWithin Hits
    1 Instant payout·· App Paid today
    2 DeclinePremium· Phone 24 hours
    3 Decline·· Email 48 hours
    4 Investigation·· Email 5 days
    5 Field adjuster·Catastrophic Phone 2 hours
    6 Field adjusterPremium· Phone 4 hours
    7 Field adjuster·· Phone 24 hours
    8 Desk reviewPremium· Phone 24 hours
    9 ··· Email 3 days

    These rules started as a paragraph of plain-English policy. Yours can too.

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